Define/Identify Population

Phase II: Develop Integrated Complex Care Systems (Whole Health Homes)


Identify a target population (TP) of individuals who are expected to benefit from care management/care coordination (CM/CC).

July – Oct 2016

  • Define the TP at the clinic/site level to include individuals with co-occurring behavioral health and medical conditions who have high risk/high needs and complexity consistent with HHP criteria and are expected to benefit from CM/CC
    • For BH organizations, stratify for individuals with medical and care management needs
  • Introduce use of Johns Hopkins’ ACG as a predictive modeling tool to stratify patients by condition, risk factors and cost
  • Using existing data sources (clinic level data, EMR and clinical staff knowledge of patients) to identify 100-300 patients as TP for BHICCI
    • Consider selecting initial TP from 1-2 interested/ engaged providers

Oct 2016 – Feb 2017

  • Use predictive modeling ca­pacity, such a ACG tool, as an ongoing predictive modeling tool to stratify pa­tients by condi­tion, risk factors and cost
  • Continue TP identification processes as needed to reach/maintain caseload of 100- 300 patients

Feb – July 2017

  • Test stepping down patient/ clients to lower level of care when clinically indicated
    • Includes stepdown for BH clients from complex medical to integrated medical care
  • Refresh TP with new patient/ clients who meet criteria
  • Spread and test use of stratification methodologies (IEHP based HCO client data) to identify HCO TP for Health Home Program

Jul 2017 – Feb 2018

  • Monitor PCP panel size and access to inform decisions about BH clinic’s capacity to provide ongoing integrated medical care to BH clients who no longer meet complex care management criteria
  • Use stratification methodologies to continue identification of patients in need of integrated complex care
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